Task-shifting to improve the reach of mental health interventions for trauma patients: findings from a pilot study of trauma nurse training in patient-centered activity scheduling for PTSD and depression

Perspectives of Nonspecialists Delivering a Brief Depression Treatment in the United States: A Qualitative Investigation

BACKGROUND

Task sharing is an implementation strategy which increases access to services by training and supporting treatment delivery by nonspecialists. Such an approach has demonstrated effectiveness for depression and other mental health outcomes; however, few studies in high-income countries have examined nonspecialist providers' (NSPs) perspectives of the acceptability, feasibility, and appropriateness of delivering mental health interventions. We examine qualitative reports of NSPs experiences delivering a brief structured behavioral intervention for depression (called "Do More, Feel Better" [DMFB]) to adults aged 55 and older.

METHODS

All NSPs (N = 4, 100%) who delivered DMFB participated in a focus group to probe their perceptions of the acceptability, feasibility, and appropriateness of both the intervention and their delivery experience as NSPs. Two coders analyzed the qualitative data from focus groups using codebook thematic analysis.

RESULTS

NSPs perceived the intervention and delivery experience to be acceptable, feasible, and appropriate. Qualitative results provided insight into specific barriers and facilitators which may be important to consider when planning to implement task sharing. Themes that emerged from qualitative data included supervision being highly acceptable and feasible, appropriateness of the intervention for NSPs, and the feasibility of tailoring the intervention to patient participants. NSPs also expressed difficulty managing emotional investment in patients' success and providing therapy during a pandemic and racial violence in the US.

CONCLUSIONS

Our results can inform future implementation and sustainment of task sharing interventions to expand access to care.

Multi-method study of the implementation of Cognitive Symptom Management and Rehabilitation Training (CogSMART) in real-world settings

Cognitive Symptom Management and Rehabilitation Training (CogSMART) and Compensatory Cognitive Training (CCT) are evidence-based compensatory cognitive training interventions that improve cognition in persons with a history of traumatic brain injury or other neuropsychiatric disorders. Despite demonstrated efficacy, use and effectiveness of CogSMART/CCT in real-world settings is not known.We used a multi-method design to collect and analyze quantitative and qualitative survey data from several domains of the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to gather information about use of CogSMART/CCT in real-world settings from provider and patient perspectives. Surveys were sent to email addresses from persons who registered on the CogSMART website seeking access to training manuals and other resources. Descriptive statistics were generated, and we used Natural Language Processing methods to study the self-report free responses. Using n-gram analysis, we identified the most frequently reported responses.We found CogSMART/CCT was broadly used in real-world settings and delivered by a variety of providers for several patient groups with high attendance and overall high satisfaction. CogSMART/CCT seemed to be offered in VA- or university-related clinics more than in private practice or rehabilitation centers. The diversity of providers and variety of formats by which to deliver CogSMART/CCT (i.e., individual, group, telehealth) seemed to play a role in its widespread implementation, as did its adaptability. Most providers made adaptations to the intervention that reduced the length or number of sessions. These changes were most likely to be based on client characteristics. The low rates of formal training, however, may have contributed to lower levels of perceived helpfulness among patients.Reach and Adoption of a cognitive rehabilitation intervention improved by increasing access to the manuals. Attention to characteristics of dissemination and implementation in the design of an intervention may enhance its use in real-world settings. The relevant outcomes, easy access to training manuals, and adaptability of CogSMART/CCT seem to have been important factors in its use in a variety of settings and for several disorders with cognitive impairment. The adoption of CogSMART/CCT by a variety of providers other than neuropsychologists suggests its use may be broadened to other healthcare providers, if adequately trained, to increase access to an intervention with demonstrated efficacy for cognitive rehabilitation for several neuropsychiatric disorders.

Behavioral Activation Disseminated by Non-Mental Health Professionals, Paraprofessionals, and Peers: A Systematic Review

There is a striking disparity between the number of individuals with significant mental health concerns and those who are able to access care globally. One promising solution to expanding the mental health taskforce is task-sharing, or employing nonspecialists in the delivery of evidence-based interventions. Behavioral activation (BA), a brief intervention that focuses on scheduling rewarding activities into one's daily life, may have promise for delivery using task-sharing approaches due to its straightforward, flexible nature. The aim of this systematic review was to examine the current state of the literature on non-specialist-delivered BA and evaluate the evidence base of this approach. Three databases (Pubmed, PsycInfo, and Cochrane) were searched, and all articles were screened for inclusion criteria by two research assistants, included the review of titles, abstracts, and full-text. The final dataset consisted of 13 research studies, represented through 15 articles. A meta-analysis was conducted to examine the overall pooled effects of peer-delivered BA on depressive symptoms (the most widely examined clinical outcome). Studies reported on effectiveness and implementation outcomes of non-specialist-delivered BA for depression, substance use, loneliness, trauma survivors, and individuals with comorbid physical health conditions. Results provide initial support for the effectiveness of BA utilizing a task-sharing approach, and highlight the feasibility and acceptability of using nonspecialists to deliver BA in a variety of contexts, including low-resource settings.

Breaking Silos to Address Medical Trauma: The Need for Integration of Trauma and Health Psychology Training

Posttraumatic Stress Disorder (PTSD) following a traumatic injury is a significant public health concern impacting approximately a third of traumatically injured patients. In 2018, the American College of Surgeons (ACS) Committee on Trauma recommended implementation of PTSD screening and brief intervention in level 1 trauma centers to meet the mental health needs of this underserved population. In March 2022, ACS revised its standards to include a requirement for mental health screening and referral process in level 1 and level 2 trauma centers. However, implementation of these programs has been limited. One barrier to implementation has been the lack of cross-trained trauma and health psychologists to support the development and implementation of trauma-focused programs in acute and critical care settings. This paper is a call to action to bring together experts in the fields of trauma and health psychology to effectively address training gaps in post-injury PTSD and medical traumatic stress. Through development of trauma and health psychology cross-training models, the field of psychology can collaborate to meet the increasing demand for trauma-focused psychologists in acute and critical care settings.

Harnessing Innovative Technologies to Train Nurses in Suicide Safety Planning With Hospitalized Patients: Protocol for Formative and Pilot Feasibility Research

Background

Suicide is the 10th leading cause of death in the United States, with >47,000 deaths in 2019. Most people who died by suicide had contact with the health care system in the year before their death. Health care provider training is a top research priority identified by the National Action Alliance for Suicide Prevention; however, evidence-based approaches that target skill-building are resource intensive and difficult to implement. Advances in artificial intelligence technology hold promise for improving the scalability and sustainability of training methods, as it is now possible for computers to assess the intervention delivery skills of trainees and provide feedback to guide skill improvements. Much remains to be known about how best to integrate these novel technologies into continuing education for health care providers.

Objective

In Project WISE (Workplace Integrated Support and Education), we aim to develop e-learning training in suicide safety planning, enhanced with novel skill-building technologies that can be integrated into the routine workflow of nurses serving patients hospitalized for medical or surgical reasons or traumatic injury. The research aims include identifying strategies for the implementation and workflow integration of both the training and safety planning with patients, adapting 2 existing technologies to enhance general counseling skills for use in suicide safety planning (a conversational agent and an artificial intelligence–based feedback system), observing training acceptability and nurse engagement with the training components, and assessing the feasibility of recruitment, retention, and collection of longitudinal self-report and electronic health record data for patients identified as at risk of suicide.

Methods

Our developmental research includes qualitative and observational methods to explore the implementation context and technology usability, formative evaluation of the training paradigm, and pilot research to assess the feasibility of conducting a future cluster randomized pragmatic trial. The trial will examine whether patients hospitalized for medical or surgical reasons or traumatic injury who are at risk of suicide have better suicide-related postdischarge outcomes when admitted to a unit with nurses trained using the skill-building technology than those admitted to a unit with untrained nurses. The research takes place at a level 1 trauma center, which is also a safety-net hospital and academic medical center.

Results

Project WISE was funded in July 2019. As of September 2021, we have completed focus groups and usability testing with 27 acute care and 3 acute and intensive care nurses. We began data collection for research aims 3 and 4 in November 2021. All research has been approved by the University of Washington institutional review board.

Conclusions

Project WISE aims to further the national agenda to improve suicide prevention in health care settings by training nurses in suicide prevention with medically hospitalized patients using novel e-learning technologies.

International Registered Report Identifier (IRRID)

DERR1-10.2196/33695

Trauma Education and Stigma Reduction in Global Settings: An Evaluation of the Impact of a One-Day Trauma Psychoeducation Workshop with Community Stakeholders in the Caribbean Nation of Saint Lucia

The independent island nation of Saint Lucia and surrounding Caribbean countries have fairly well-documented high reported rates of trauma, but limited training infrastructure for trauma-related mental health support and treatment services. This study addresses this disparity between high trauma exposure and sparse trauma-related resources by studying how a one-day training workshop impacted self-rated knowledge about trauma and stigma towards trauma survivors. The training was provided by a licensed clinical psychologist in partnership with a local women's rights group. Participants (n = 41) included school counselors, nurses, psychiatric providers, health educators, and advocates on the island. Participants completed pre- and post-workshop measures examining the variables of interest. The one-day workshop provided training on trauma types, post-trauma reactions, options for treatment, and hands-on training for trauma crisis-management and short-term interventions. Following the workshop, participants reported increased knowledge of trauma, more accurate perceptions of its prevalence, better understanding of evidence-based treatments, and lower trauma survivor-related stigma. This is the first trauma-focused workshop tested in St. Lucia, where the need for such training is considerable given few treatment options for trauma survivors in this area. Work is underway to provide more expansive services for trauma across the Caribbean region, given these preliminary promising findings.